U.S. Liver Organization Recommends That People With Hepatitis C Be Tested for Hepatitis B Before Starting Antiviral Therapy

The American Association for the Study of Liver Diseases (AASLD) is the premier U.S. liver research organization. The AASLD engages in many activities, including holding conferences and providing advice for physicians caring for patients with liver disease caused by viral hepatitis, particularly hepatitis B virus (HBV) and hepatitis C virus (HCV). The AASLD also produces guidelines for the screening, care and treatment of people with viral hepatitis in cooperation with another organization, the Infectious Diseases Society of America (IDSA).

Advances in HCV treatment

In the past several years, all-oral regimens called direct-acting antivirals (DAAs) have been approved in Canada, the U.S. and other high-income countries for the treatment of people with HCV. Overall, these regimens are highly effective, well tolerated and used for a shorter period of time than older therapy (a combination of interferon and ribavirin). As a result, more people are being treated for chronic HCV infection.

Beware of HBV co-infection

Some people who are infected with HCV are also co-infected with other viruses such as HBV and HIV. Both HCV and HBV infect the liver and can cause serious liver injury if left untreated. Sometimes when people co-infected with HCV and HBV are treated with DAAs but not also treated for HBV, their hepatitis B virus can flare up or reactivate -- infecting more liver cells which in turn produce more copies of HBV. This rise in HBV can cause liver injury.

In September 2016, the AASLD-IDSA's committee tasked with drafting treatment guidelines (called the Guidelines Panel) issued a press release about HCV treatment and HBV screening, stating the following:

"All patients beginning HCV treatment using DAA therapies should be assessed for HBV."

Raymond Chung, M.D., co-chair of the Panel, said that "cases of HBV reactivation during or after DAA therapy for HCV have been reported in HBV/HCV co-infected patients who were not already on HBV suppressive therapy." He added, "The severity of these cases has ranged from mild to severe liver injury that can be life threatening. While we do not know how frequently this occurs, the Panel recommends HBV testing for all patients beginning DAA treatment for HCV."

Furthermore, the Panel made the following recommendations:

  • HBV vaccination for all susceptible individuals (i.e., those not immunized or without evidence of response to immunization)
  • obtaining a test for HBV DNA prior to DAA therapy in patients who could be actively replicating (i.e., those who are HBsAg positive)
  • starting patients who meet criteria for treatment of active HBV infection on therapy at the same time -- or before -- HCV DAA therapy is initiated
  • monitoring patients with low or undetectable HBV DNA levels at regular intervals (usually not more frequently than every four weeks) for HBV reactivation during treatments and placing those whose HBV DNA levels meet treatment criteria on HBV therapy as recommended by the AASLD's HBV treatment guidelines

Panel co-chair Susanna Naggie, M.D., M.H.S., noted: "While there currently isn't enough data to make clear recommendations for patients who have been exposed to HBV and resolved the virus, whether spontaneous or after antiviral therapy, we recommend these patients be monitored for HBV reactivation. This is particularly important in the event of unexplained increases in liver enzymes and during and/or after completion of DAA therapy."

For more information about AASLD-IDSA's recommendations for the testing, care and treatment of people with HCV go to www.hcvguidelines.org/.



AASLD. People with hepatitis C should be tested for hepatitis B before starting antiviral therapy. Press release. 16 September 2016. Available at: www.aasld.org/about-aasld/pressroom/people-hepatitis-c-should-be-tested-hepatitis-b-starting-antiviral-therapies